REVIEW OF DISABILITY STUDIES: AN INTERNATIONAL JOURNAL Volume 13 Issue 2 Editorial Thinking About Immigration and Disability Raphael Raphael RDS Associate Editor for Multimedia & Creative Works The state and the body are always connected. In times of crisis (political and economic), there is often increasing concern with borders, both of the nation and of the body. It becomes “urgent” to protect the state from contagions and threats, real or imagined. With increasing urgency, leaders often attempt to unify their base by clearly articulating what it means to be a "normal citizen,” identifying which bodies are included and which are not. We can see this connection between body and state both in the present and in the past. History is replete with examples, and the lessons are not subtle. As the Third Reich consolidated power in 1933, among their first actions was to identify people with disabilities as enemies of the state. Just six months after assuming power, they passed the Law for the Prevention of Progeny with Hereditary Diseases. On one hand, the physically strong and independent Übermensch (superman) served as powerful symbol of a strong independent German state. On the other hand, there was perhaps no more inconvenient sign than people with disabilities: inconvenient truths of the vulnerability of bodies, of their needs and undeniable interdependence. Eliminating these inconvenient bodies became an important early step in nation-building, and the muted national response to their elimination became a tragic rehearsal for much larger atrocities. (See Liz Crow’s short film Resistance (2009) and David Mitchell and Susan Snyder’s upcoming Disposable Humanity.) Our present moment reflects a great deal of border anxiety. There’s rhetoric of literal wall building to protect and reify imaginary and geographic borders and a troubling rise of isolationist/anti-immigrant rhetoric in the United States and Europe. The rising chorus of voices saying which bodies should be citizens and which should not marks a shift that has taken many in the world by surprise: there was near global shock to the assumption of power by the current POTUS in the US and to the passage of Brexit in Great Britain, as well as to the recent near-miss in closely watched elections in France. At least in the United States, this rise in border anxiety appears to coincide with increasing government disdain (or at least apparent disinterest) in the needs of those with disabilities. The current POTUS, who as a candidate famously mocked a reporter with disabilities, has a pattern of choosing appointees with apparent disinterest in the needs of people with disabilities. It was widely reported that now Secretary of Education Betsy DeVos appeared confused about basic legal protections afforded to all students with disabilities. As recently as May 24th, Ms. Devos refused to say she would refuse federal funds to schools that discriminated against students with special needs. The confirmation hearing of Supreme Court nominee Neil Gorsuch, revealed a seemingly similar lack of concern: a case showed him unnecessarily ruling against a student with autism, a questionable ruling the Supreme Court subsequently rebuked (during his actual confirmation hearings). Some rhetoric in current efforts at immigration reform has also evoked the danger posed by immigrants drawing on public services in ways that could easily target those with disabilities for exclusion. While this particularly anxious moment has taken many by surprise, immigration and disability have long been tied in the history of the United States. Two centuries ago, with the Immigration Act of 1882, the country identified people with disabilities as potential “threat to the nation” and has since had a long history of using disability as criteria for immigration exclusion (See Daniel J. Wilson’s “‘No Defectives Need Apply’: Disability and Immigration.” OAH Magazine of History 23 [July 2009]: 35-40.) Today, the ‘ideal’ citizen has been more explicitly tied to religion and ethnicity than to issues of ability, with Islamic people the immediate subject of particularly intense suspicion. At the same time, history suggests it’s wise for us to keep mindful of possible slippages of otherness, slippages that frequently allow these fears to bleed to the body and to disability. With a view shared by many, embattled former National Security Advisor Michael Flynn famously described Islam in biological terms, as a “cancer” threatening national security and as a “sick” ideology that, per his tweet, “needs to B [sic] healed.” The US administration’s recent attempt at a Muslim ban attempted to “cure” this “sickness.” As the effects of early exclusion policies still echo and debates rage over who belongs, who does not belong, who is worthy of entrance, who is not, a great deal of attention is rightly paid to the ethnic and religious dimensions of the debate. Perhaps we should give more attention to also considering the ways in which disability may intertwine with these. In a time when nations are actually increasingly interdependent, with a variety of bodies—with a variety of needs—often living in flow between nations, perhaps the greatest threat is pretending this isn’t so. And in this chain of bodies that need one another and have the power to speak out for one another, now more than ever, as Martin Niemöller reminded us, it doesn’t matter who they come for first. ________________ Research Article The Changing View of Physical Recreation for People with Disabilities in the USA: A More Inclusive Perspective? Anna Brady, Keith Christensen (PhD), Judith Holt (PhD) Utah State University Abstract: Historically, people with disabilities have had limited access to physical recreation. However, as society’s view of people with disabilities and their rights has been in transition, so has physical recreation activities for people with disabilities. The purpose of this study is to examine the transition of physical activity for people with disabilities in the United States. A three-fold search process of databases, ancestral, and descendent searches were conducted, yielding sixteen studies for inclusion in this historical literature review. The results show that the earliest physical recreational opportunities for people with disabilities were based in medical response to physical needs. Today, opportunities for physical recreation for people with disabilities include therapeutic and non-therapeutic activities. Nonetheless, there is still a division in how society views recreation for people with disabilities, represented by major recreation organizations holding either medical or sociopolitical views of people with disabilities. Keywords: people with disabilities, recreation, history Introduction Physical recreation activity is valuable for all people (World Health Organization, 2015). Research shows that physical recreation activities provide many health benefits, such as reducing the risk of many types of diseases, cancers, and diabetes (World Health Organization, 2015). Other benefits of physical recreational activity include reducing hypertension, reducing depression, and controlling weight (World Health Organization, 2015). Moreover, many people engage in physical recreation activities due to its intrinsic benefits, such as relaxation and social interactions (Bullock & Mahon, 2001; Hurd & Anderson, 2011; Nesbitt, 1979). Physical recreation activities are a fundamental human right, according to the United Nations’ Declaration of Human Rights (UDHR), “Everyone has the right to rest and leisure” (Universal Declaration of Human Rights, 2006). Article 30 also recognizes that people with disabilities have the right to partake in recreation activities: “[…] Participate on an equal basis with others in recreational, leisure, and sporting activities” (UDHR, 2006). Society’s dominant view of people with disabilities and their rights has been in transition (Linton, 1998; Palmer & Harley, 2012; Smart, 2009b). Linton (1998) highlights six ways that society has classified people with disabilities, ranging from denying people with disabilities any of their civil rights to limiting people with disabilities’ role in society to providing people with disabilities opportunities to participate in all areas of their communities. Historically, the United States has held a medical view of people with disabilities, where the individual with the disability was responsible for fixing his/her disability, and doctors were viewed as the experts in helping people with disabilities overcome their disability (Palmer & Harley, 2012; Smart, 2009a; Smart, 2009b; US Commission on Civil Rights, 2000). Moreover, this medical view of disabilities views disability as a problem, deviance, or something abnormal (Palmer & Harley, 2012; Smart, 2009b). This suggests that people with disabilities may be excluded from areas such as recreation, thereby reducing their integration into communities and their quality of life. The Civil Rights movements of the 1960s in the U.S. represented a major change in society’s view of people with disabilities (DePauw & Gavron, 2005; Smart, 2009a; Smart, 2009b; US Commission on Civil Rights, 2000). Society began to shift from a predominantly medical view of disability toward a sociopolitical view of disability (Smart, 2009b). From the sociopolitical perspective, people with disabilities are no longer seen as deviant, but rather as people who are entitled to their rights in society. Rather than delegating the responsibility of disability to the medical profession, the sociopolitical view posits that all members of society are responsible for including people with disabilities in the mainstream (Palmer & Harley, 2012; Smart, 2009b). But it was not until 1990 with the passage of the Americans with Disabilities Act that people with disabilities’ civil rights were affirmed and it became illegal to discriminate against people with disabilities in the public sector (ADA.gov, n.d.). As society’s understanding of people with disabilities’ fundamental human rights has shifted in the past century, physical recreation activities for people with disabilities have also changed. Current research explains the shift from the therapeutic to non-therapeutic recreation, but it appears outdated and does not examine how this parallels the shift from a purely medical model of disabilities to a sociopolitical view of disabilities (e.g., Blas, 2007; Nesbitt, 1983; Szyman, 1993). It also fails to explain how recreation is viewed from recreation providers for people with disabilities. The purpose of this study is to examine the transition of physical recreation for people with disabilities in the United States. This historical literature review examines when/how has physical activity for people with disabilities in the USA transitioned? Definitions For more than thirty years, physical activity has been defined as “any body of movement produced by skeletal muscles that requires energy expenditure” (Caspersen, Powell, & Christensen, 1985; World Health Organization, 2015). Recreational therapy’s long-standing definition is “a treatment service designed to restore, remediate and rehabilitate a person’s level of functioning and independence in life activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restriction to participation in life situations caused by an illness or disabling condition” (American Therapeutic Recreation Association, 2015). All of which are redeeming values. Recreation is defined as “an activity that people engage in during their free time, that people enjoy, and that people recognize as having socially redeeming values” (Hurd & Anderson, 2011), in addition to secondary physically redeeming values. The definition of sport in the literature varies, but it is commonly recognized that sport is a type of physical activity that has rules, is a competition, and is performed for enjoyment (e.g., Hurd & Anderson, 2011; Wheelchair & Ambulatory Sports, USA, n.d.). Therefore, the key difference between recreational therapy and recreation is that recreational therapy is a service provided to a person, whereas recreation is something that a person chooses to engage in during his/her free time. Also, recreation can be done without a therapist and without specific habilitation goals in mind (Bullock & Mahon, 2001). Sports are considered as part of recreation, except when those who engage in the sports are paid. Therefore, this article does not include the history of Paralympics, as many of these athletes receive some sort of payment (e.g., sponsorship) for their participation. Notably, the Paralympics parallel the development of other recreation opportunities for people with disabilities. That is, the first athletes in the opening 1960 Paralympics were individuals with spinal cord injuries, and slowly other types of disabilities began to join (DePauw, 2013). Methods Inclusion/Exclusion Criteria Since this is a historical literature review, there were no date limits set for this search process. A three-fold search process of databases, ancestral, and descendent searches were systematically conducted according to inclusion and exclusion criteria outlined below. In order to narrow the focus on this review, the authors chose to focus on only the history of physical recreation in the USA. Articles were included if they contained information about physical recreation opportunities for people with disabilities. No specific limits were set on the types of disabilities; that is, articles were included if they only focused on one type of disability (e.g., physical) or on multiple types of disabilities (e.g., physical and intellectual). Due to the language limitations of the authors, only sources that were available in the English language were included. Books, chapters from books, peer-reviewed journal articles, and articles from recreation publications were included in this review. Exclusion criteria included: no people with disabilities mentioned, countries other than the USA, and source not available in English. Search Methods The following databases were searched during September, 2015: Psych Info, Hobbies & Crafts Reference Center, Psych & Behavioral Sciences, and Sport Discuss. Psych Info and Psych & Behavioral Sciences were chosen because of their robust inclusion of studies with people with disabilities. Hobbies & Crafts Reference Center was chosen because it includes many types of recreational activities. Likewise, Sports Discuss was chosen because it focuses on research related to sports. These databases captured such journals as the American Journal of Sports Medicine, Therapeutic Recreation Journal, and Adapted Physical Activity Quarterly. The following combinations of search terms were used: “disability + recreation + history,” “disability + recreation therapy + history,” “recreation therapy + history,” and “disability + history + therapeutic recreation.” This yielded 444 sources, and their titles and abstracts were screened for relevance. Sources were deemed relevant if they included historical information on either recreation or therapeutic recreation for people with disabilities in the USA. For example, the title of one study excluded during title screening was, “The story of sport for children and youth with disabilities in Latvia.” Likewise, the majority of studies were excluded because they either focused on countries outside the USA or because they merely explained types of recreation for people with disabilities without explaining the history of how this type of recreation evolved. An example of an included article is, “Thirty-seven years of community recreation for people with disabilities.” This article was included because it covered the history of recreation for people with disabilities, and the abstract revealed that it focused on the USA. The ancestors (i.e., references) of the articles that passed this initial screening were also screened for relevance. Additionally, each of the articles obtained through the database searches and ancestral searches were screened for their descendants (i.e., later publications that cited an obtained article). When new descendant articles were obtained, their references also were screened. The combined ancestor and descendent searches yielded an additional 811 citations that were screened. Google Scholar was also searched using the aforementioned search terms to capture relevant gray literature, which yielded over 247,000 hits. Therefore, only the first 100 hits per set of search terms were screened. The Google Scholar searches yielded no new sources. Overall, 16 articles and books were selected for inclusion in this literature review. Figure 1 gives an overview of the systematic historical literature search and screening process. ________________ Figure 1 Flow-chart of the systematic historical literature review and screening process. Alternative text description – The image depicts flow chart of the systematic historical literature review and screening process. The flow chart categorized in four sections and labeled “Identification”, “Screening”, “Eligibility”, and “Included” in the flow chart. In the identification category there are three different starting point boxes, the first box includes description “Records identified through database searching (n=444)”, the second box includes description “Records identified through ancestor and descendent searching (n=444)”, and the third box includes description “Additional records identified through Google Scholar (n = 247,000).” In the screening category, there are two different boxes. The first and second box in the identification section flows into the screening section’s first box that includes description “Records screened by title and abstract (n = 1,255).” The third box in the identification section flows into the screening section second box that includes description “First 100 hits per search screened; yielded no new sources.” In the eligibility category there are two different boxes. The first box in the screening section flows into two different box, the first box includes description “Full-text articles assessed for eligibility (n = 40)” and the second box includes description “Full-text articles excluded (n = 24) (reasons: countries outside the USA (n = 4) and no explanation of evolution of recreation n = 20).” In the included category there is one box in which box one from the edibility box one flows into a box with the description includes “Studies included in qualitative synthesis (n = 16).” Discussion of Results Overview Because the majority of the literature on the evolution of physical recreation for people with disabilities is qualitative in nature, a thematic synthesis was used to analyze the literature to identify the themes and present the themes in narrative, chronological format (Barnett-Page & Thomas, 2009). Specifically, the following themes were identified: therapeutic recreation, non-therapeutic recreation, society’s changing perspective on physical activity for people with disabilities, major recreational organizations’ role in this changing perspective, and the expansion of non-therapeutic recreation. Each of these themes will be discussed below. Therapeutic Recreation As one researcher explains, recreation is “as old as recorded history” (Nesbitt, 1979, p. 12). Notably, the earliest formal recreation programs that included individuals with disabilities were therapeutic in nature. Some of the earliest roots of recreational therapy can be traced to the 1880s in the USA. During this time, physical activity and sports began out of a “medical concern” for the “correction of physical disabilities” (Mason, 2002, p. 82). Beginning in the 1900s, there is growing evidence of recreation for people with disabilities that was seen as having benefits other than just therapeutic. Many institutions, services for veterans, and options for children with disabilities began to offer recreational opportunities for people with disabilities. During the 1930s, the United States’ Veterans Administration created and provided recreational therapy services for veterans (Nesbitt, 1983). In the Works Progress Administration, the USA’s government stated the purpose of therapeutic recreation as “all activities, regardless of type, carried on for the benefit of disabled, maladjusted, or other institutionalized persons” (WPA Gov Docs, 1938). This definition reflects the widely held therapeutic mindset of the time, which viewed recreation for people with disabilities as rehabilitative in nature. The 1940s brought an increase in therapeutic recreational services. During World War II, the American National Red Cross provided many therapeutic services to veterans in military hospitals and clinics (Austin, 2004; Nesbitt, 1983). As with many aspects of disability history, veterans were an early catalyst for societal acceptance and investment in individuals with disabilities (Smart, 2009a). Following this historical pattern, therapeutic recreation services moved slowly from veterans’ programs to public programs. In 1948, the Hospital Recreation Section of the American Recreation Society became the first professional organization for recreational therapy (Austin, 2004). The 1950s and 1960s ushered in a rise of recreational therapy organizations (Austin, 2004; Nesbitt, 1983). Generally, these were associated with medical institutions or associations, reflecting the emphasis on society’s “medical concern” for people with disabilities. As highlighted above, the earliest formal efforts in the USA of recreation for people with disabilities emphasized the therapeutic benefits of recreation. Nevertheless, access to recreational opportunities was generally only available through veterans and disability service institutions and organizations as a “service.” It was not until the mid-twentieth century that organizations began to publically recognize recreation as having benefits beyond therapeutic. Non-Therapeutic Recreation As early as 1906, records of institutions for people with disabilities in the USA indicate that many institutions had designated staff in charge of recreation (Nesbitt, 1983). From 1906-1909, the Playground Association of America surveyed institutions such as orphanages and homes for people with disabilities and found that many of these homes had appointed key people to provide recreational services. In the 1910s, the Hospital for Crippled Children and School for Crippled Children provided recreational options for people with disabilities, such as camp experiences. Mirroring that seen for therapeutic recreation, in 1917, the American National Red Cross provided recreation for veterans (Nesbitt, 1983). These institutional programs, camp experiences, and recreation for veterans outside of hospital settings demonstrate some of the USA’s earliest physical activities without therapeutic purposes for people with disabilities. The types of non-therapeutic recreational opportunities provided for people with disabilities increased in the 1920s, though most of these options were targeted for children with disabilities. This marked a shift from prior services that were targeted for veterans. In the Northeastern USA, disability camps for children with diabetes began (Eells, 1986). From 1921 to 1926, the Russell Sage Foundation provided training on recreation and physical education for many schools and institutions for children with disabilities (Nesbitt, 1983). In 1924, the Deaf Olympics formed (Legg, Emes, Stewart, & Steadward, 2004). These children’s programs and the Deaf Olympics were non-therapeutic recreation options, as their purpose was to provide people with disabilities opportunities to engage in activities during their free time that did not have rehabilitative purposes. During the 1930s, non-therapeutic recreational opportunities for people with disabilities began to expand beyond just options for children with disabilities. Specifically, the Recreation Center for the Adult Physically Handicapped in New York and the Recreation Department of Akron, Ohio opened (Nesbitt, 1983). Throughout the 1930s and 1940s, summer camp programs for children with disabilities continued to expand (Blas, 2007). Just as the camps and programs for people with disabilities in the 1920s did not have therapeutic purposes, so Akron’s Recreation Center and these new summer camp programs did not have therapeutic goals. Instead, the goals of these camps were to provide camping options for children with disabilities that were similar to their nondisabled peers (Blas, 2007; Nesbitt, 1983). The 1940s saw an increase in non-therapeutic recreational options for people with disabilities that were a direct response to the WWII veterans with physical disabilities returning from war. In particular, many types of wheelchair sports, such as wheelchair bowling and basketball, became popular during this time (Neishloss, 1973; Szyman, 1993). In 1945, the first wheelchair basketball games for veterans were held, and in 1948, the first wheelchair games for civilians formed (Szyman, 1993). These new sports and recreational options were purely recreational in nature as opposed to having therapeutic purposes. During the 1950s, non-therapeutic recreational opportunities for people with disabilities continued to increase. During this time, the San Francisco Recreation Center for the Handicapped, one of the first major recreation centers for children and adults with disabilities, opened (Nesbitt, 1983; Pomeroy, 1990). This Center included many types of recreational activities, such as outdoor environmental activities, aquatics, physical education, and theatre (Pomeroy, 1990). The first national wheelchair games, which exemplified non-therapeutic recreational opportunities for people with disabilities in the USA, were held in 1957 (DePauw & Gavron, 2005). These wheelchair games were organized by Wheelchair Sports, USA; the Paralyzed Veterans of America; and Adelphi College in New York (DePauw & Gavron, 2005; Wheelchair & Ambulatory Sports, n.d.). The 1960s brought continued growth of non-therapeutic recreational options for people with disabilities (Nesbitt, 1979). In 1960, the USA wheelchair sports team competed internationally for the first time (DePauw & Gavron, 2005). The US government began to see the rising need for professionals who were trained in recreation for people with disabilities, and so the US Office of Vocational Rehabilitation offered grants for “training master’s-level specializations in recreation for the ill and handicapped” (Nesbitt, 1983, p. 101). Likewise, the Physical Education and Recreation for Handicapped Children Section of the Mental Retardation Act Amendments provided research and training funds for recreation for children with disabilities (Nesbitt, 1983). In 1968, Special Olympics, which provided competitive sports opportunities for people with intellectual disabilities, was founded (Legg et al., 2004; Orelove, Wehman, & Wood, 1982). Throughout the twentieth century, recreation opportunities for people with disabilities continued to expand. Most importantly, these opportunities reflected a change in society’s view of people with disabilities. That is, recreation activities were no longer viewed as primarily therapeutic; rather, many of these activities allowed people with disabilities to engage in recreation at their own discretion during their free time. For example, children’s camping options and competitive wheelchair sports were just a few of the growing number of recreational activities for people with disabilities in the USA. Society’s Changing Perspective While the origins of recreation options for people with disabilities were rooted in the medical model, as the twentieth century progressed, recreation for people with disabilities expanded to include purposes beyond just therapy, reflecting a societal shift towards a sociopolitical view of disabilities. One author explains, “[t]he origins of physical activities and sport for people with disabilities are rooted in medical concern…for the ‘correction’ of physical disabilities through the use of exercise and physical therapy” (Mason, 2002, p. 82). The first individuals with disabilities who accessed physical recreation activities that were not seen as mainly therapeutic were veterans of WWII who had acquired physical disabilities (Mason, 2002; Stein, 1983). The Civil Rights Movements in the 1960s sparked dramatic changes not only in African-Americans seeking their civil rights, but people with disabilities began to seek their civil rights as well (DePauw & Gavron, 2005; Smart, 2009a). This era was a turning point for recreation and people with disabilities as several new pieces of legislation formally recognized people with disabilities’ rights (DePauw & Gavron, 2005). Legislation that opened up doors for people with disabilities’ recreational options included the Education of All Handicapped Children Act of 1975 (renamed IDEA in 1990) and the Amateur Sports Act of 1978. Specifically, IDEA mandated a free, appropriate education for children with disabilities in public schools, which allowed these children access to physical education activities as well. The Amateur Sports Act recognized athletes with disabilities as part of the United States Olympic Committee (DePauw & Gavron, 2005). These laws reflect society’s shift towards inclusion of people with disabilities in recreational activities. Major Organizations’ Influences on Recreation Just as laws began to reflect society’s shifting view of people with disabilities, several key organizations in the USA began to reflect this shift away from the medical model of disability. For example, towards the end of WWII, the Red Cross issued a statement that “recreation is an end unto itself” and further stated that their organization’s activities were not therapeutic (James, 1980, p. 14). This statement may have been the result of economic and other pressures; specifically, at the end of WWII, the Red Cross had a lack of funds which decreased the number of workers who could provide services to veterans. Also, around this time, the Surgeon General challenged the Red Cross that their untrained workers were providing occupational therapy services (James, 1980). Therefore, in an effort to eradicate any responsibility of their dwindling number of workers from providing therapeutic services, the Red Cross announced that their recreational services were “an end unto itself” and not therapeutic (James, 1980, p. 14). The Red Cross workers shifted from providing recreation services that were therapeutic to providing services that were for diversionary or enjoyment purposes (Bullock & Mahon, 2001; James, 1980). This marked a shift from seeing recreational opportunities as being always therapeutic to being seen as having other purposes (James, 1980). Another key turning point in the shift from viewing recreation as only therapeutic occurred with the formation of the National Therapeutic Recreation Society (NTRS) in 1966 (Austin, 2004). This organization posited that recreation could have nonclinical purposes for all people, and that recreation could also be used as clinical therapy (Austin, 2004). During this time, there was a growing debate between major recreation and therapeutic recreation organizations about the use and meaning of the term “therapeutic recreation” (Austin, 2004). In 1970, these major organizations came together in a meeting at Indiana State University to try to come to a consensus on the meaning of “therapeutic recreation.” However, Austin points out that no agreement could be reached during this meeting, and the organizations continued to debate the meaning of the term “therapeutic recreation” well into the 1980s. In 1984, the American Therapeutic Recreation Association (ATRA) was formed with the sole focus on defining therapeutic recreation as providing clinical therapy purposes only. This organization’s philosophy reflects the medical model of disabilities, which views people with disabilities in need of fixing. The formation of the ATRA marked a division into two ideas of therapeutic recreation. That is, the NTRS maintained their stance that recreation could be for all people with or without having therapeutic benefits, while the ATRA held that therapeutic recreation had clinical purposes (Austin, 2004). Thus, these two organizations’ philosophies of recreation highlight the opposite perspectives of people with disabilities from the sociopolitical model and the medical model, respectively. Currently, the NTRS is a branch of the National Recreation and Park Association. The NTRS provides recreational services in both the clinic and community setting (NTRS, 2005). The NTRS posits that everyone has a right to leisure and that engaging in leisurely (i.e., non-therapeutic) activities increases one’s quality of life, which demonstrates their position that recreation can be therapeutic and non-therapeutic in nature (NTRS, 2005). The NTRS’s perspective on recreation reflects a sociopolitical mindset, in that people with disabilities are not viewed merely as in need of medical rehabilitation. Rather, NTRS’s view of recreation for people with disabilities is a more inclusive view, as most people without disabilities also engage in recreation for non-therapeutic reasons. In contrast, the ATRA maintains their stance that therapeutic recreation has therapeutic, health-related benefits. The ATRA’s website states that their “services play a critical role in the comprehensive rehabilitation of individuals with illnesses and/or disabling conditions” (Welcome to the ATRA, 2015). Indeed, the ATRA views their services as primarily a health care treatment for people with disabilities, which is a direct contrast to the NTRS’s position that recreation can be therapeutic and non-therapeutic. Today, recreational opportunities for people with disabilities involve those that are both therapeutic and non-therapeutic, which reflects the perceived benefits of both as well as society’s still-divided views of people with disabilities. Disability researchers note that society still holds contrasting views of people with disabilities, such as seeing people with disabilities as deficits in need of medical fixing to seeing people with disabilities as being limited only by the barriers society puts in place (Linton, 1998; Palmer & Harley, 2012; Smart, 2009a; Smart, 2009b). For example, recreational therapy reflects the medical viewpoint of people with disabilities, which sees people with disabilities as needing treatment from medical experts to help alleviate the effects of their disabilities (Smart, 2009a). In contrast, recreational options for people with disabilities that are not therapeutic in nature reflect a sociopolitical view of disabilities, whereas people with disabilities are hindered from participating in recreation only because of the barriers imposed by other people (Palmer & Harley, 2012; Smart 2009b). Expansion of Non-therapeutic Recreation Today, there are literally hundreds of non-therapeutic recreational opportunities for people with disabilities. For example, the Christopher & Dana Reeve Foundation lists many recreational resources for people with disabilities on their website. This list exemplifies the vast array of different types of non-therapeutic recreational opportunities that are available, such as national park services, surfboarding, figure ice skating, geocaching, golf, and many more (Reeve Foundation, 2015). Additionally, while there are many organizations that are specifically focused on providing recreation for people with disabilities, many organizations provide parallel recreation for people with and without disabilities. For example, the Chicago Park District (CPD) provides mostly separate services for people with and without disabilities. The CPD’s website lists many recreation activities for people with disabilities under their “adapted sports” or “special recreation” sections, whereas it lists activities aimed at people without disabilities under other general categories by the name of the sport, such as “martial arts” or “ice skating.” While the CPD’s Special Recreation offers specialized programs for the following populations: blind or visually impaired, Deaf or hard-of-hearing, intellectual disabilities, physical disabilities, Special Olympics, and veterans, it unclear if these programs are integrated with people without disabilities (Chicago Park District, 2014). Many parks and recreation programs across the USA offer similar programs as those in Chicago, although whether or not these programs are integrated reflects the continuing transition in how society views individuals with disabilities. For example, Special Olympics programs and Deaf and Hard-of-Hearing programs are presumably only for people with disabilities, which reflect the continued separation between people with and without disabilities. A typical posting of a Deaf event at a park on the CPD’s website explains that the target population for this activity is “individuals whose primary disability is deafness or heard-of-hearing.” Likewise, postings for the CPD’s special recreation activities specify that these events target “individuals with a primary intellectual or developmental disability” (Chicago Park District, 2014). Postings on the CPD’s website that do not target people with disabilities generally are categorized by age, but typically do not specify if these programs are open to people with disabilities. While people with disabilities have access to many more types of recreational programs than in the past, these programs still largely run parallel to programs for people without disabilities. Summary Our review explored the historical trends of recreation for people with disabilities in the USA. As with any historical literature review, this account is subject to the interpretive lens of the authors. Also, the dearth of information available, especially information on early recreation and therapy options for people with disabilities, is another limitation. Additionally, the focus on the history of recreational therapy in the USA limits the scope of this review. Future research could comparatively explore the transition of recreational therapy to non-therapeutic options in other countries. Though originally viewed as having purely therapeutic purposes, by the mid-twentieth century, alternative views of recreation began to form. Additionally, although recreational opportunities for people with disabilities began mainly with services for veterans, these options expanded to include children with disabilities, and eventually recreation for all ages and types of disabilities began to form throughout the USA. Most of the literature still reflects a medical view of people with disabilities. That is, most of our sources emphasized people’s disabilities and how recreation can help people with disabilities. Even sources that do not claim that recreation need always be therapeutic often stressed other health benefits of recreation, such as reducing the risk of diseases, cancers, and diabetes. While not specifically claiming that recreation must be therapeutic for people with disabilities, by highlighting these other benefits, the literature still reflects a medical mindset of trying to help improve the lives of people with disabilities through recreation. Furthermore, none of these sources discussed the development of recreation for people with and without disabilities, thus highlighting the division that society places between people with and without disabilities. Another noteworthy fact is the types of disabilities that are discussed in the literature. That is, most of the literature on physical activities for people with disabilities focuses on people with physical disabilities, with a smaller amount of attention on physical activities for people with intellectual disabilities (e.g., Special Olympics). This current literature review revealed virtually no literature on the evolution of physical activities for people with sensory, learning, or emotional disabilities. Future research could compare the historical physical recreation experiences of people with different types of disabilities. Just as society is still in transition (Linton, 1998; Palmer & Harley, 2012; Smart, 2009a), so too is recreation, as many recreational programs for people with disabilities are still segregated from people without disabilities. As society continues to shift its perspective in realizing that societal barriers hinder people with disabilities, this shift leads to including people with disabilities in all areas of the community. Therefore, as society becomes more inclusive of people with disabilities, recreational opportunities will likely become more integrated. While recreation has tended to follow society’s leading in its view of people with disabilities, recreation could shift from merely following society’s lead to being a leader in societal change. By systematically creating more programs that include both people with and without disabilities, recreation can be a catalyst for further integration of people with disabilities. Anna Brady is a doctoral student in the Disability Disciplines program at Utah State University (USU). Her areas of emphasis are disability studies and applied behavior analysis. Dr. Keith Christensen is an Associate Professor in the Landscape Architecture and Environmental Planning Department at Utah State University. His areas of expertise include the following: socially equitable planning and design, inclusive environments, socially accessible play environments, universal design, and research methods and statistical techniques. Dr. Judith Holt is an Associate Professor in the Special Education and Rehabilitation Department at Utah State University. Dr. Holt directs several projects at the Center for Persons with Disabilities, working with the Maternal and Child Health Bureau (MCH), the Office of Special Education and Rehabilitative Services (OSERS), the Center for Disease Control and Prevention (CDC), and the Association of Developmental Disabilities (ADD). References Austin, D. R. (2004). Therapeutic recreation: A long past, but a brief history. Palastra, 20(1), 37-42. Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: A critical review. BMC Medical Research Methodology, 9(59), 1-11. Blas, H. I. (2007). A specialized program for children with developmental disabilities within a “typical” overnight summer camp: Camp Ramah’s Tikvah Program. Child and Adolescent Psychiatric Clinics of North America, 16, 875-886. Bullock, C. C., & Mahon, M. J. (Eds.) (2001). Introduction to recreation services for people with disabilities: A person-centered approach. (2nd edition). Champaign: Sagamore Publishing. Caspersen, C., J., Powell, K. E., & Christensen, G. M. (1985). Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports, 100(2), 126-131. “Chicago Park District Special Recreation.” (2014). Retrieved 12 November 2015, from Chicago Park District’s website: http://www.chicagoparkdistrict.com/programs/chicago-park-district-special-recreation/ “Convention on the Rights of Persons with Disabilities.” (2006). Retrieved 26 October, 2015, from http://www.un.org/disabilities/convention/conventionfull.shtml DePauw, K. P., & Gavron, S. J. (2005). Disability sport. (2nd edition). Champaign: Human Kinetics. DePauw, K. P. (2013). A historical perspective of the paralympic games. Journal of Physical Education, Recreation, & Dance, 83(3), 21-31. Eells, E. (1986). The movement spreads out. In Eleanor Eells’ history of organized camping: The first 100 years. p. 99-116. Hurd, A., & Andersen, D. (2011). Definition of leisure, play, and recreation. In The park and recreation professional’s handbook. Champaign: Human Kinetics. Retrieved 24 September 2015, from: http://www.humankinetics.com/excerpts/excerpts/definitions-of-leisure-play-and-recreation “Introduction to the ADA.” (n.d.). Retrieved 12 October 2015, from the United States Department of Justice’s website: http://www.ada.gov/ada_intro.htm James, A. (1980). Historical perspective: The therapy debate. Therapeutic Recreation Journal, 14(1), 13-16. Legg, D., Emes, C., Stewart, D., & Steadward, R. (2004). Historical Overview of the Paralympics, Special Olympics, and Deaflympics. Palaestra, 20 (1), p. 30-35. Linton, S. (1998). Claiming disability: Knowledge and identity. New York: New York University Press. Mason, F. (2002). R. Tait McKenzie’s medical work, and the beginnings of physical activity programs for people with disabilities. In North American society for sport history. p. 82-83. Ontario. “National Therapeutic Recreation Society.” (2005). Retrieved 12 November 2015, from the National Recreation and Park Association’s website: https://www.recreationtherapy.com/history/ntrs/ntrs2005archive.htm Neishloss, L. I. (1973). Origin and development of wheelchair bowling. Rehabilitation Literature, 34 (6), 173-175. Nesbitt, J. A. (1979). The 1980s: Recreation a reality for all. Education Unlimited, 1 (2), 12-19. Nesbitt, J. A. (1983). Recreation for handicapped in the United States: A historical perspective. In Adapted physical activity, from theory to application. p. 95-110. Orelove, F. P., Wehman, P., & Wood, J. (1982). An evaluative review of Special Olympics: Implications for community integration. Education and Training of the Mentally Retarded, 17 (4), 325-329. Palmer, M., & Harley, D. (2012). Models and measurement in disability: An international review. Health and Policy Planning, 27, 357-364. “Physical Activity.” (2015). Retrieved 24 September 2015, from the World Health Organization’s website: http://www.who.int/topics/physical_activity/en/ Pomeroy, J. (1990). Thirty-seven years of community recreation for persons with disabilities. In Global Therapeutic Recreation I: Selected Papers from the 1st International Symposium on Therapeutic Recreation. P. 25-31. “Recreation Resources for People with Disabilities.” (2015). Retrieved 12 November 2015, from the Christopher and Dana Reeve Foundation’s website: http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.9087173/k.DAD3/Recreation_Resources_for_People_with_Disabilities.htm “Recreational Therapy.” (2011). From: Health Care Careers Directory. Chicago: American Medical Association. Retrieved 25 September 2015, from: http://caahep.org/Context.aspx?ID=61 Smart, J. (2009a). Disability, society, and the individual. Austin, TX: Pro-ed. Smart, J. F. (2009b). The power of models of disability. Journal of Rehabilitation, 75(2), 3-11. Stein, T. A. (1983). Recreation and special populations. Boston: Allyn & Bacon, Inc. Szyman, R. J. (1993). North American Zone Development & Issues: History of wheelchair basketball & North American zone. In Proceedings manual from the Third International Wheelchair Basketball Symposium for coaches, athletes, and officials: July 11 & 12, 1992, Edmonton, AL. p. 56-61. “The Universal Declaration of Human Rights.” (2015). Retrieved 12 October 2015, from the United Nations’ website: http://www.un.org/en/documents/udhr/ United States Commission on Civil Rights. (2000). Sharing the dream: Is the ADA accommodating to all? Washington, D. C.: The Commission. Retrieved 12 October 2015, from the United States Commission on Civil Rights’ website: http://www.usccr.gov/pubs/ada/ch1.htm “Welcome to the ATRA.” (2015). Retrieved 12 November 2015, from the American Therapeutic Recreation’s website: https://www.atra-online.com/welcome/the-organization “What is RT/TR?” (2015). Retrieved 25 September 2015, from: American Therapeutic Recreation Association’s website: https://www.atra-online.com/what “Wheelchair & Ambulatory Sports, USA.” (n.d.). Retrieved 12 November 2015, from: http://www.wasusa.org/aboutus.htm “Works Progress Administration, Gov Docs.” (1938). Retrieved 30 November 2015, from: http://archive.org/stream/Leisureleadership/leisureleadership_djvu.txt Research Article Changing Disability Status of Immigrants in Australia - Three Cases Qingsheng Zhou The University of Sydney Abstract: This paper examines the changing disability status over five years of those born overseas who have lived in Australia for various periods of time. Sourcing data from the 2006 and 2011 censuses it explores in-depth three distinctive immigrant groups: recent immigrants arriving between 2002 and 2006; Chinese students coming to Australia in the late 1980s; and Vietnamese refugees settling in Australia in the late 1970s and early 1980s. The analysis shows that age is the most important factor influencing the trajectories of disability profiles of immigrants, just like their local counterparties. Keywords: Australia, immigrants, disability statistics Introduction This study deals with the changing disability profiles of immigrants to Australia.1 Australia has a largely immigrant population and successive waves of migration since European settlement have resulted in a highly culturally diverse society. According to the Australian Bureau of Statistics (ABS), at 30 June 2014, 28% (6.6 million people) of the population was born overseas. About half of Australians are either immigrants themselves (overseas born), or children of immigrants (at least one parent born overseas). An understanding of the disability characteristics of immigrant communities is crucial to the continued improvement of support systems to meet the changing needs of Australians with disability. Using the latest population statistics over the period 2006-2011 this paper demonstrates that while immigrants generally have a lower rate of disability on arrival, they tend to acquire disability at a much faster pace as they age than other Australians. Research Question This study questions how the disability status of Australian immigrants has changed over the five-years between 2006 and 2011. The relationship between immigrants of particular origins, their length of residence in host countries, and their health, wellbeing and specific diseases has been a subject of many studies (Alter and Oris, 2005; Gray, Harding and Reid, 2007; Harding, 2004; Johansson, Helgesson, Lundberg, Nordquist, Leijon, Lindberg, and Vingard, 2012). A recent review of the literature on the health status of migrants in Australia concludes that “migrants in Australia are generally in better health compared with the Australian-born population”(Anikeeva, Bi, Hiller, Ryan, Roder. and Han, 2010). This so-called ‘healthy migrant effect’ has also been used to understand the disability of immigrants. When explaining the relatively low presence of people born overseas in the specialist disability services, the Australian Institute of Health and Welfare (AIHW, 2010), for instance, state that: “Immigrant populations often have lower death and hospitalisation rates, as well as lower rates of disability and lifestyle-related risk factors. To some extent, this can be explained by the fact that most migrants are partly selected on the basis of their health and, in some cases, their relatively high socioeconomic status.” Zhou (2015) recently probed whether disability status of immigrants could be understood in the same way as that on the healthy migrant effect. Zhou revealed that Australians born overseas have the same level of disability and a greater level of profound and severe disability. In particular, immigrants who mainly speak a language other than English at home have relatively higher levels of need for assistance than English speaking groups. However, Zhou’s study as a snapshot does not explore the issue of changes in disability status over time. Just like the health status of individual immigrants, disability is not static and will change over time through manifestation, acquiring, improving or deteriorating (Mutchler, Prakash, and Burr, 2007). These changes are embedded in an acculturation process which all immigrants experience to various degrees. In this process individuals or groups transition from living one lifestyle to the lifestyle of another culture, exposing them to a new physical and social environment, requiring them, at least to some extent, to adapt to new behaviours, values, customs, and language. Consequently, the trajectories of their disability status may be altered. The time factor also includes a natural process of aging that tends to result in a greater rate of disability. Another factor associated with disability of immigrants is the selection processes by which people who voluntarily or involuntarily move to another country, and are filtered through immigration regulations of the host country. People settle in a different country for a variety of reasons, including family reunion, economic and political considerations, security necessity, lifestyle persuasion and access to government services. While both ‘self’ selection and ‘policy’ selection exist, it is debatable whether health status plays any significant role in the decision-making process (Findley, 1988; Kaestner and Malamud, 2014). Relating to these self-selection processes is the factor of country of origin. It emphasizes the importance of disability profile of countries of origins of immigrants. Countries at different stages of development tend to have different levels of disability prevalence (World Health Organization and The World Bank, 2011). Countries that have suffered from major natural disasters or wars may have an increased prevalence of disability. Subsequently immigrants from these countries may have disability profiles that are different from their host country. While the disability profiles of immigrants differ from their local population and this is a result of many intertwining factors, it is the impact of this time factor that this study attempts to explore. Each year, a certain number of immigrants arrive in Australia under a variety of programs. What happens to these people over a five-year period in terms of their disability? Data and Method This study uses the disability definition adopted by the Australia Bureau of Statistics (Australia Bureau of Statistics, 2006) in the five yearly Census of Population and Housing (the Census hereafter) and sources the data from the two most recent censuses, 2006 and 2011. Being a complex and difficult concept to define and measure, disability is the umbrella term for impairments, activity limitations and participation restrictions, referring to the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) (WHO, 2001). Interpretation of disability varies from person to person and is also likely to vary across time for individuals. On a personal level, individuals may be reluctant or unable to identify themselves as having particular types of disabilities. In a data collection setting, responses to a disability question may be sensitive to the survey context – for instance, asking questions about other topics before asking questions on disability may encourage or discourage a particular type of response. It is especially difficult to capture the full complexity of the experience of living with a disability and accurately assess the full range of disability severity with a limited number of questions (ABS, 2007a). Recognising this complexity, and aiming to overcome the difficulties, the ABS developed a two-dimensional measure for disability data collection. The first dimension, reflecting the International Classification of Functioning Disability and Health (ICF) activities and participation domains, says that a person has a disability if the person has a limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts a range of daily activities (Australia Bureau of Statistics, 2013). These daily activities are further divided into core activities, namely: self-care, mobility and communication, and non-core activities. The second dimension addresses how frequently – always or sometimes – a person needs assistance in these daily activities. People who have limitations in one of three core activities and always or sometimes require assistance in these areas are classified as having a profound or severe disability. The 2006 Census, for the first time, implemented the two-dimensional measure through a short disability module. It asked each person four disability-related questions: Whether the person ever (always or sometimes) needs someone to help with, or be with for (1) self-care; (2) body movement and (3) communication activities (Questions 20–22), and whether the reasons for the need for assistance in these questions are (1) short-term health condition; (2) long-term health condition; (3) disability; (4) old or young age; (5) difficulty with English language and (6) other cause (Question 23) (Australia Bureau of Statistics, 2005). The ABS however was only able to release an aggregated variable of ‘‘having need for assistance’’ that is derived from these four questions. This variable categorises people as needing assistance if they reported always or sometimes needing help in at least one of the three core areas of self-care, mobility or communication because of a disability, long-term health problem (lasting 6 months or more) or old age. Therefore, responses are coded to the category ‘‘does not have need for assistance with core activities’’, when the response to Question 23 is only ‘‘difficulty with English language’’ (ABS, 2006). Needing assistance with one or more of these activities is interpreted as an indication that someone has significant difficulties with basic human functions. These questions were repeated in the 2011 Census. These questions identify a population that is conceptually comparable to those with severe or profound core activity limitation which is targeted by specialist disability services in Australia (CSTDA, 2003; Evidence Base Development Unit, 2010, COAG, 2009), although it has been widely recognised that the disability population identified through the Census could not be directly interpreted as the prevalence rate of disability. To avoid using a long description such as, “people who have core activity need for assistance” and for ease of reading, this study simply uses terms the “disability” and “disability rate” to refer to this population. This study primarily relies on disability statistics from census data (2006 and 2011) because of its size and comprehensive coverage which enables the examination of small populations by demographic, geographic or economic characteristics.2 The statistics presented in this study are not only sourced from the ABS standard publications but are also derived from special runs from the ABS TableBuilder. The TableBuilder allows researchers to access and manipulate census information in an unprecedented way (ABS, 2014). However, statistics sourced from these products may often be slightly different from other ABS publications, primarily due to how TableBuilder deals with the small counts. The study identifies three distinctive subpopulations of immigrants from the censuses. The first is the most recent arrivals who came to Australia during 2002-2006. The second is the Chinese students who had arrived in Australia between 1989 and 1991. The third are those Vietnamese who sought refuge in Australia between 1977 and 1986. When they came to Australia, these people had different disability profiles. The 2006 census collected information about their disability status at the time when they had lived within local communities for different durations. Their disability status is reported again five years later in the 2011 Census, using the exact same survey instrument. Changes in these subgroups over this five-year period are examined in turn within the context of when and from where they came. Analysis Results Recent Arrivals - Case One The first group are those who were born overseas and settled in Australia in the five years (2002 to 2006) prior to the 2006 Census. This group was more than half a million from all over the world (ABS, 2007b). This section examines the disability rates for these people in 2006 and compares them with their disability rates reported in 2011 Census. Figure 1 plots the changes in disability rates for immigrants who arrived in Australia in each of these five years. In addition to the all-age combined column, Figure 1 shows three other typically reported age cohorts: 5-19 years, 25-34 and 60-79 in 2006. Each colour represents a specific year of arrival and each line depicts the disability rates in 2006 and 2011 for approximately the same cohort. Meanwhile, for comparison purposes, the disability rates of other Australians who are not recent arrivals are presented by dark black lines. The image above depicts a line graph titled Figure 1: Changes in Disability Rages of Recent Immigrants between 2006 and 2011 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0.0% to 14.0% and the x-axis provides 4 categories: all ages, age 5-16 (in 2006), age 25-34 (in 2006) and age 60-79 (in 2006). Each category provides line measurements between 2006 Rate and 2011 rate and each year is indicated by a color , pink represents arrived 2002, light purple represents arrived 2003, dark purple represents arrived 2004, yellow represents arrived 2005, green represents arrived 2006, black represents other. In addition, numbered measurements are provided on the graph in the all ages category measures 2006 at 4.5% and 2011 at 5.0%, age 5-19 category measures 2006 at 2.0% and 2011 at 2.1%, age 25-34 category measures 2006 at 1.4% and 2011 at 1.7%, and age 60-79 category measures 2006 at 9.0% and 2011 at 14.0%. Alternative text description – The image above depicts a line graph titled Figure 1: Changes in Disability Rates of Recent Immigrants between 2006 and 2011 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0.0% to 14.0% and the x-axis provides 4 categories: all ages, age 5-16 (in 2006), age 25-34 (in 2006) and age 60-79 (in 2006). Each category provides line measurements between 2006 Rate and 2011 rate and each year is indicated by a color, pink represents arrived 2002, light purple represents arrived 2003, dark purple represents arrived 2004, yellow represents arrived 2005, green represents arrived 2006, black represents other. In addition, numbered measurements are provided on the graph in the all ages category measures 2006 at 4.5% and 2011 at 5.0%, age 5-19 category measures 2006 at 2.0% and 2011 at 2.1%, age 25-34 category measures 2006 at 1.4% and 2011 at 1.7%, and age 60-79 category measures 2006 at 9.0% and 2011 at 14.0%. Figure 1 shows that while the new arrivals as a whole clearly have fewer disabilities than their local counterparts, they are not all without disabilities. Relatively higher proportions of older new arrivals have a disability than younger people, resulting in an age-related disability distribution. The later arrivals have a lower rate of disability than those coming a few years earlier, indicating that some immigrants had an acquired disability, or their disability conditions had manifested in just a few years after arriving in Australia. For example, immigrants just arrived in 2006 as a whole reported the lowest rates of disability for all age cohorts, represented by the light green lines while those arrived in 2002 have much higher rates by 2006. Furthermore, every cohort experienced an elevated rate of disability between 2006 and 2011, as indicated by the fact that the slopes of all lines go up. In other words, regardless of age at arrival and disability rate at arrival, more people acquired disability over the five years to 2011. However, older age cohorts acquire more disability at a much faster rate than younger ones, as shown by the varied degrees of the slopes for those aged 60-79. For instance, the upward trend of the lines for the youngest cohort (5-19 years in 2006) are minimal, meaning a very small increase over the five years as opposed to the older cohort of 60-79 year-olds for whom rates increase considerably regardless of arrival year. The sharpest rise is in the rates of those immigrants who arrived in 2006 when 60-79 years, from 7.2% to 16.8% over the five year reporting period. Last, while recent arrivals overall have a lower rate of disability than other Australians, it may not be as clear-cut for older age cohorts. For example for those immigrants who were 60 to 79 years in 2006, only those who arrived in 2006, 2005 and 2004 have disability rates that are lower than that of other Australians. Nonetheless it is clear that older immigrants acquire disability at a much faster rate than both younger immigrants and other older Australians. Chinese Students - Case Two It is well documented that there were a number of “rushes” of Chinese immigrants to Australia with the most recent one occurring between 1989 and 1991 (Museum Victoria Australia, 2014). In Australia this group of Chinese immigrants is widely known as the Chinese students because the majority were student visa holders.3 According to ABS censuses, between 1986 and 1991 the China-born population in Australia more than doubled. Unlike earlier Chinese settlers these immigrants arrived in the late 1980s predominantly from families who could afford to pay college fees which were a substantial amount for a Chinese family at the time (Jupp, 2001). After about twenty years living in Australia, they still report as a distinctive and stable population in the 2006 and 2011 censuses as seen in table 1 that compares the year of arrival of these Chinese students and their age ranges. For easy reading their age ranges are derived and presented both as in 1991 (showing they were mostly between 20 and 45 at the time of arrival) and at census times. The fact that the great majority of these people entered Australia under the student visa category means they had a healthy profile. Few, if any would have had a disability. These characteristics make it a good data set for this study to evaluate the relationship between duration of stay and disability. The image above depicts a bar graph titled Figure 2: Disability Rate and Immigrants from China Arrived between 1989-91 and provides source ABS Census Tablebuilder, Author’s analysis. The y-axis ranges from 0.0% to 12.0% and the x-axis provides 3 categories: Arrival in 1989, Arrival in 1990, and Arrival in 1991. Each category provides 5 different measurements in 2006 and 2011 and the 5 different measurements are indicated by different colors, orange measures 25-29/40-44/45-49, red measures 30-34/45-49/50/54, green measures 35-39/50-54/55-59, purple measures 40-44/55-59/60-64, and blue measures 45-49/60-64/65/69. Alternative text description – The image above depicts a bar graph titled Figure 2: Disability Rate and Immigrants from China Arrived between 1989-91 and provides source ABS Census Tablebuilder, Author’s analysis. The y-axis ranges from 0.0% to 12.0% and the x-axis provides 3 categories: Arrival in 1989, Arrival in 1990, and Arrival in 1991. Each category provides 5 different measurements in 2006 and 2011 and the 5 different measurements are indicated by different colors, orange measures 25-29/40-44/45-49, red measures 30-34/45-49/50/54, green measures 35-39/50-54/55-59, purple measures 40-44/55-59/60-64, and blue measures 45-49/60-64/65/69. Figure 2 plots the disability rates in 2006 and 2011 of the Chinese students who arrived at Australia for each of the three years between 1989 and 1991. Each colour represents a specific age cohort measured at the year of arrival. The cohorts are organised according to the age ranges which are presented as the time of arrival,4 Census 2006 and Census 2011 for easy reading. Three observations can be drawn from Figure 2. The first is the different rate of disability among varied age cohorts in 2006 by which time the students would have lived in Australia for about 15 years. At the beginning of the 15 years, all cohorts were young and healthy students assumed to be without a disability. Some fifteen years later, older age cohorts have a much greater disability rate than younger age cohorts. For example, for those who arrived in 1989, only 0.5% of those aged 23-27 had acquired a disability by 2006, however 0.8% of the 28-32 had acquired it, and as high as 5.6% of these 20 years older had acquired it. In other words, if the assumption holds that few of these people had a disability when visas were granted, then age is clearly an accelerating factor in disability rates. The second observation is that every age cohort experienced a deterioration of disability status within the 5 years without any exception. For example, as indicated by the orange bars, 0.5% of those who arrived in 1989 when aged 23-27 reported a disability in the 2006 Census. Five years later, in 2011, 1.2% reported having a disability. Similar increases are reported for those who arrived in the next two years. All other age cohorts show a similar upward direction of disability. Thirdly, and perhaps most surprisingly, disability rates for those who were aged 45-49 at arrival (60-64 in 2006) reached 5.6%, 8.1% and 6.6% which is on par with the rest of Australians in that age range. Five years later in 2011, these rates become as high as 9.1%, 11.0% and 7.9%, which are around the overall rate of disability for all Australians in that age range (10.9%). In other words, living in Australia for 15-20 years has made the Chinese students the same as other Australians in terms of their disability profile. Vietnamese Refugees - Case Three The term ‘boat people’ entered the Australian vocabulary in the late 1970s with the arrival of the first wave of boats carrying Vietnamese people seeking asylum. Over half the population in Vietnam at the time was displaced in these years and, while most fled to neighbouring Asian countries, some embarked on the voyage by boat to Australia. Between 1976 and 1981 more than two thousand Vietnamese boats arrived at Australia (Phillips and Spinks, 2013) and a larger number of Vietnamese refugees came to Australia via air. The 1976 Census, in which the Vietnamese were recorded separately for the first time as a country of origin, reports less than 2,400 people born in Vietnamese in Australia. In the 1981 Census, the Vietnamese born population had bloomed to 41,000. By 1986 the number doubled to 83,000. This research identifies those Vietnamese immigrants who arrived in Australia during the period 1977 to 1986 as the third case group. Between 1975 and 1986, almost all of the Vietnamese arrivals were refugees, making this cohort of immigrants distinctive from later Vietnamese immigrants.5 According to an ABS analysis based on the 1986 Census, the Vietnamese immigrants were different from many other immigrant communities in their higher proportion of younger people, poorer ability to speak English, many not living as a family member but as a boarder in a family, lower levels of school education and employment (ABS, 1991). These characteristics indicate that Vietnamese refugees in Australia were a distinctive, disadvantaged socioeconomic community in the mid-1980s. The image above depicts a bar & line graph titled Figure 3: Number and Age Composition of Vietnamese Immigrants Arriving in 1977-89 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 2,000 to 12,00 and 0% to 80%. The x-axis provides 10 categories: Arrived 1977, Arrived 1978, Arrived 1979, Arrived 1980, Arrived 1981, Arrived 1982, Arrived 1983, Arrived 1984, Arrived 1985, and Arrived 1986. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with green measures 45&+/65&+/70&+, red measures 20-44/40-64/45-69 and blue measures <20/20-39/25/44. In addition, there are line graphs which intersects with the bar graphs Age at arrival/2006/2011 with green measures 45&+/65&+/70&+, red measures 20-44/40-64/45-69 and blue measures <20/20-39/25-44. Alternative text description – The image above depicts a bar & line graph titled Figure 3: Number and Age Composition of Vietnamese Immigrants Arriving in 1977-89 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 2,000 to 12,00 and 0% to 80%. The x-axis provides 10 categories: Arrived 1977, Arrived 1978, Arrived 1979, Arrived 1980, Arrived 1981, Arrived 1982, Arrived 1983, Arrived 1984, Arrived 1985, and Arrived 1986. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with green measures 45&+/65&+/70&+, red measures 20-44/40-64/45-69 and blue measures <20/20-39/25/44. In addition, there are line graphs which intersects with the bar graphs Age at arrival/2006/2011 with green measures 45&+/65&+/70&+, red measures 20-44/40-64/45-69 and blue measures <20/20-39/25-44. Figure 3 shows the sudden increase and count of Vietnamese immigrants in these five years by year of arrival as reported in the two Censuses. It also shows that the age composition of the arrivals from Vietnam had shifted to having a higher proportion of young refugees in the second half of the ten year period. During the earlier years, about a quarter of the Vietnamese refugees were under 20 years old but in the final years they were about 40%. This shift would have implications for the disability of Vietnamese immigrants as a whole some 20 to 30 years later. While it is clear that few Chinese students came to Australia with a disability; it is not necessarily the case for Vietnamese refugees at the time of arrival. Their specific characteristics means the understanding of changing status of disability over 2006 and 2011 will provide an interesting case study, in comparison to the previous two cases. By the year 2006 when the Census, for the first time, started to collect information on disability, the refugees arriving in the 10 years to 2006 had lived in Australia 20-30 years. Figures 4a and 4b plot the disability rates reported in censuses 2006 and 2011 of Vietnamese refugees who arrived at Australia annually between 1977 and 1986 in the same manner as the earlier analysis of the Chinese immigrants. However, for presentation purposes we break the ten-year period into two sub-periods of five-years each (Figures 4a & 4b). While this is primarily because of presentation need the break point in 1981/82 is also consistent with a shift in the nature of these immigrants.6 These figures exclude the rates for age cohorts of the very young and very old, as these are based on small counts that have also been randomly adjusted by ABS for privacy reasons. Bar graph titled F4a: Disability Rates of Vietnamese Immigrants Arrived between 1977-81 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis provides 5 categories: Arrived 1977, Arrived 1978, Arrived 1979, Arrived 1980, and Arrived 1981. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with dark blue measures 10-14/40-44/45-49, red measures 15-19/45-49/50-54, dark green measures 20-24/50-54/55-59, dark purple measures 25-29/55-59/60-64, teal measures 30-34/60-64/65-69, orange measures 35-39/65-69/70-74, light purple measures 40-44/70-74/75-79, pink measures 45-49/75-79/80-84, light green measures 50-54/80-84/85-89 and light purple measures 55-59/85-89/90-94. Alternative text description – The image above depicts a bar graph titled F4a: Disability Rates of Vietnamese Immigrants Arrived between 1977-81 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis provides 5 categories: Arrived 1977, Arrived 1978, Arrived 1979, Arrived 1980, and Arrived 1981. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with dark blue measures 10-14/40-44/45-49, red measures 15-19/45-49/50-54, dark green measures 20-24/50-54/55-59, dark purple measures 25-29/55-59/60-64, teal measures 30-34/60-64/65-69, orange measures 35-39/65-69/70-74, light purple measures 40-44/70-74/75-79, pink measures 45-49/75-79/80-84, light green measures 50-54/80-84/85-89 and light purple measures 55-59/85-89/90-94. bar graph titled F4b: Disability Rates of Vietnamese Immigrants Arrived between 1981-86 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 90% and the x-axis provides 5 categories: Arrived 1982, Arrived 1983, Arrived 1984, Arrived 1985, and Arrived 1986. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with dark blue measures 10-14/35-39/40-44, red measures 15-19/40-44/45-49, dark green measures 20-24/45-49/50-54, dark purple measures 25-29/50-54/55-59, teal measures 30-34/55-59/60-64, orange measures 35-39/60-64/65-69, light purple measures 40-44/65-69/70-74, pink measures 45-49/70-74/75-79, light green measures 50-54/75-79/80-84 and light purple measures 55-59/80-84/85-89. Alternative text description – The image above depicts a bar graph titled F4b: Disability Rates of Vietnamese Immigrants Arrived between 1981-86 and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 90% and the x-axis provides 5 categories: Arrived 1982, Arrived 1983, Arrived 1984, Arrived 1985, and Arrived 1986. Each category provides 2 different bar measurements in 2006 and 2011 and in each bar there are multiple measurements Age at arrival/2006/2011 with dark blue measures 10-14/35-39/40-44, red measures 15-19/40-44/45-49, dark green measures 20-24/45-49/50-54, dark purple measures 25-29/50-54/55-59, teal measures 30-34/55-59/60-64, orange measures 35-39/60-64/65-69, light purple measures 40-44/65-69/70-74, pink measures 45-49/70-74/75-79, light green measures 50-54/75-79/80-84 and light purple measures 55-59/80-84/85-89. Figures 4a and 4b not only confirm two general patterns that were identified in the earlier Chinese case analysis but also reveal some unexpected trends. First of all, by 2006 when these refugees had lived in Australia for some 20-30 years, the disability rates for people of different ages settled into a pattern that is similar to those of the general population. Older Vietnamese refugees tend to have a higher rate of disability than younger refugees. Take, as an example, the refugees who arrived in 1980 (the year with the largest number of arrivals); the disability rates increase progressively with the increase in age by 2006. Second, between 2006 and 2011, almost every age cohort experienced a deterioration of disability rates. On average, 4.1% of all Vietnamese immigrants reported a disability in 2006. Five years later this rate increased to 5.9%. As the age spread of Vietnamese refugees is much wider than the Chinese students, the deterioration could be observed in both the younger and older age groups. At the youngest end, there are those as young as 10 years on arrival and about 40 years old in the census times; on the oldest end, there are those who were aged in their late 50s on arrival and in about their 90s at the census times. Of the 90 pairs of bars which compare the rates between 2011 and 2006 and are presented in Figure 5a and Figure 5b, 83 pairs show an increased rate. Bar graph titled 5a: Disability Rates in 2006 – Selected Immigrant Groups and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis titled Age in 2006: with ages 20-94 with 4 different categories Australia born, 2006 arrivals, 1989-91 arrivals from China and 1977-86 arrivals from Vietnam. Alternative text description – The image above depicts a bar graph titled 5a: Disability Rates in 2006 – Selected Immigrant Groups and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis titled Age in 2006: with ages 20-94 with 4 different categories Australia born, 2006 arrivals, 1989-91 arrivals from China and 1977-86 arrivals from Vietnam. Bar graph titled 5b: Disability Rates in 2011 – Selected Immigrant Groups and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis titled Age in 2011: with ages 20-94 with 4 different categories Australia born, 2006 arrivals, 1989-91 arrivals from China and 1977-86 arrivals from Vietnam. Alternative text description – The image above depicts a bar graph titled 5b: Disability Rates in 2011 – Selected Immigrant Groups and provides source ABS Census TableBuilder, Author’s analysis. The y-axis ranges from 0% to 80% and the x-axis titled Age in 2011: with ages 20-94 with 4 different categories Australia born, 2006 arrivals, 1989-91 arrivals from China and 1977-86 arrivals from Vietnam. Moreover, and not surprisingly, older age cohorts have much greater increases in disability rates than younger age cohorts over these five years. For example, more than 80% of those in the oldest group who arrived in Australia in 1984 reported having disability in the 2011 Census, compared to 52% five years previously in 2006. Careful readers might observe missing bars in Figures 4a and 4b. These are missing due to either there being no count of particular age groups. Another unexpected finding is in the disability 2006 profile for the first year arrivals (1977) that is strikingly different from those of other later years in that the correlation between age and disability rate is not as smooth. Upon further investigation of the data it was apparent that this untypical distribution was primarily due to the small cell count. As Figure 4a shows, the number of Vietnamese refugees in the first year (1977) is relatively small (less than 2,000 are reported in the 2006 Census). When this small number is further broken down by age and disability status, the numbers become too small to be statistically reliable. In addition, random adjustments performed by the ABS to protect privacy might have further distorted the underlying distribution that may be expected, as for the arrivals in other years. Discussion This paper examined the disability rates of three distinct immigrant groups over varied residence periods. The first group included those born overseas, old and young, who came to Australia up to five years prior to the 2006 Census. They came from all over the world for a variety of reasons. The short time between their arrival and the 2006 census means their reported disability status is treated as a proxy of the status at the time of entry. By the time of the 2011 Census, they had lived in Australia for at least five years. The second group, Chinese students, came to Australia in the late 1980s. They were predominantly student visa holders and few, if any, would have had a disability at the time of entry. By the 2006 Census, most of these people had been settled in Australia for more than 15 years. The final group, Vietnamese refugees, arrived in Australia in the late 1970s and first half of the 1980s. They were different from the first group in being from a single country of origin and being refugees. The Vietnamese were more diverse than the Chinese students in their age range, health and socioeconomic status and had lived in Australia for up to 30 years by the time of the 2006 census. Analyses of these different immigrant groups suggests that age is one of the most important factors influencing the trajectories of disability status over the period 2006-2011. It has long been established that disability rate increases steadily with age (ABS, 2013). Disability prevalence tends to be much higher for older people regardless of the wealth of the country they live in (World Health Organization and the World Bank, 2011: Table 1 and Table 2). The data presented here make it evident that this is true for immigrant communities as well. Recent immigrants to Australia present with considerably lower rate of disability than local communities of the same age who were Australia born or arrived earlier than them. To begin with, there exists considerable variation amongst these new arrivals in their level of disability. The older recent arrivals have higher rates of disability than the younger ones. One possible reason for this is that these older immigrants with a disability came to Australia primarily for family reunion. Even when Australian immigration regulation makes it unlikely that they came to Australia with a disability, which is reflected by a lower disability rate at the time of arrival (Figure 5a), they might have acquired a disability shortly after they landed in Australia. In a time-span of just five years, the rates of disability of young immigrants are in line with local people of the same age cohorts. For older cohorts (60 and over), the rates of change are much faster than that experienced by locals. After just five years, most of the older age cohorts of immigrants reported higher rates of disability than the local population (Figure 5b). The Chinese student group presented similar trends over 15 to 20 years; although very few of them would have had any disability upon arrival. Some 15 years later, the rates of disability by age show a difference in age-related distribution that is similar to the local populations. More remarkable is the number of Chinese students in the older cohorts who had acquired a disability in the five years between 2006 and 2011; a much faster increase than that reported by the local born population in 2011 (Figure 5b). Interestingly, of those senior Chinese when arrived in the late 1980s their disability rates had reached the same level as the local population before 2006. For Vietnamese refugees, disability rates surpassed those of the local population for all cohorts over 50 years old by the year 2006 by which time they had lived in the Australia for about three decades (Figure 5a). Five years later in 2011, the gaps had become even greater. An intriguing question about the disability trajectory of immigrants in their host country is the amount of change since the time of entry. The present study had limited success in exploring this specific change as there are no comparable disability statistics at the time of entry. When examining the case of recent arrivals, we are able to take the 2006 statistics as a proxy of the disability profiles of these new arrivals because they have not lived in Australia long. In the case of Chinese students, it is assumed that few of these students had a disability at the time of entry. The study makes no assumption about the disability status of the Vietnamese boat people at the time of entering Australia. Instead it focuses the on changing status between 2006 and 2011. This study makes no effort to untangle acculturalization processes in which the changes in disability status of immigrants occur. Immigrant communities, by definition, originated from different cultures, and individuals within these communities may interact with the local communities differently. At the same time they also influence and contribute to the hosting cultures as well. In an Australian context, immigrants have become the mainstream as more than a quarter of Australians were born overseas and more than half have at least one parent who was born overseas. Acknowledging the process of acculturalisation and its impacts on the disability, this study focuses on the latter on these first generation immigrants. Clearly older immigrants tend to acquire disability faster than their local counterparts. However, it is not clear why this trend exists and what factors contribute to this trend. New research is required to answer these questions in order to develop effective social policy responses. Any new research must be multidisciplinary in nature in order to adequately explore the complex relationship between disability, aging and cultural diversity. Only through a multidisciplinary approach will researchers be able to assist policy makers to identify ways to change the disability trajectory of people from CALD backgrounds, to slow down the rate of disability manifestation and acquisition, and to develop culturally appropriate services to an increasing number of people with disabilities from CALD backgrounds in both disability and aged care service settings. Conclusion Of the current Australian population, about a quarter are first generation immigrants. While immigrants might as a whole have a rate of disability that is lower than their hosting population at the time of their arrivals, they are not a homogenous group. Few of these immigrants had a disability when arriving, some others acquired disability or their disability conditions manifested after their arrival. As demonstrated in this paper, age is the most important factor influencing the trajectories of disability status of immigrants, just like their local counterparties. Not surprisingly older immigrants tend to have a higher rate of disability than younger cohorts upon arrival. Furthermore, the older the immigrants are the faster they acquire disability. In about a generation, immigrants tend to have an aged related disability profile that is similar to the rest of the community. It is important to not underestimate this rate of the change when developing government policy and program design for specialist disability and aged care services. Qingsheng Zhou Senior Research Fellow, National Centre for Classification in Health, Faculty of Health Sciences, The University of Sydney. References Alter G and Oris M. (2005). 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History of immigration from China. Retrieved from https://museumvictoria.com.au/origins/history.aspx?pid=9. Mutchler, J. E., Prakash, A., & Burr, J. A. (2007). The demography of disability and the effects of immigrant history: Older Asians in the United States. Demography, 44(2), 251-263. New South Wales Department of Education. (2015). Australian Communities: Vietnamese Australians. Retrieved from http://www.racismnoway.com.au/teaching-resources/factsheets/76.html. Phillips, J., & Spinks, H. (2013). Boat arrivals in Australia since 1976. Department of Immigration and Citizenship, Parliamentary Library: Australian Government. Retrieved from http://parlinfo.aph.gov.au/parlInfo/download/library/prspub/5P1X6/upload_binary/5P1X6.pdf;fileType=application/pdf#search=%22boat%20arrivals%20in%20Australia%20since%22. World Health Organisation. (2001). International classification of functioning disability and health. Retrieved from http://www.who.int/classifications/icf/icf_more/en/. World Health Organization. (2011). World report on disability. World Health Organization. Zhou, Q. (2016). Accessing disability services by people from culturally and linguistically diverse backgrounds in Australia. Disability and Rehabilitation, 38(9), 844-852. Endnote 1 There are many ways to classify and count immigrants. This study adopts a simple and practical definition that an immigrant is a person who is born in a different country and comes to live for a considerable period of time in Australia, as self-reported in the Census of Population and Housing (ABS, 2006). 2 The ABS (2015) generally recommends the uses of standard error (SE) and relative standard error (RSE) to indicate statistical reliability of any estimates based on the SDAC. Such indicators however are not necessary when the Census data are used as they cover the whole population and are therefore not subject to sampling error. 3 In the late 1980s, there was an increase in the number of people from China enrolling in post graduate studies in Australia universities. Meanwhile Australia came touting for Chinese students, offering visas and the chance to study English in private colleges for a fee. Consequently a large number of young Chinese rushed to Australia, not merely for the chance to study, but also the possibility of a new life. In 1989, the Australian government granted permanent visas to most Chinese students in the aftermath of the Tiananmen Square incident (Sydney Morning Herald, 2003 Dec 26). Several months later, a large number of Chinese citizens who had received a student visa prior to the Tiananmen incident also landed on Australia soil. Most of these people permanently settled in Australia. 4 For simplicity, arrival ages are based on 1991. 5 This decreased to around 45 per cent between 1986 and 1991 and only 22 per cent between 1991 and 1993 (NSW Department of Education, 2015). 6 In 1979, the Vietnamese government agreed to forcibly constrain unregulated departures, but to allow an Orderly Departure Program (ODP) in which Vietnamese were permitted to apply to migrate to specific countries. In 1982 the first Vietnamese immigrants under the ODP arrived in Australia. From the late 1980s this program was officially applied in Australia as the ‘Vietnamese Family Migration Program’ (VFMP). Under this program Vietnamese people with relatives in Australia were permitted to emigrate directly from Vietnam to Australia, subject to satisfying Australia’s standard refugee requirements. ________________ Research Article Neighborhood Effects on Social Participation of Children With and Without Disabilities Mansha Mirza (PhD) and Yoonsang Kim (PhD) University of Illinois at Chicago Abstract: Few studies have examined how neighborhood characteristics affect the social participation of children with and without disabilities. Analysis of survey data from 20 low-income U.S. neighborhoods confirmed that neighborhood safety and stability influence social participation. Furthermore, children with disabilities have lower odds of social participation, though disparities vary by location. Keywords: disability studies, health, developmental studies Disabled activists and disability studies scholars have long argued that disability is not an inherent trait within individuals, but, rather, is an experience that results from interaction between individuals and their environment. Thus various aspects of the environment, including built features, sociocultural norms, political context, and economic resources, can hinder or foster disabled individuals’ participation in society (Field & Jette, 2007). Consequently, it is important to understand how different environments, such as residential, work, and community, affect the participation of people with disabilities. The current paper addresses this topic with a specific focus on neighborhood environments where families reside, and their influence on participation of children with and without disabilities. There is growing interest in the effects of residence in poor urban neighborhoods on a variety of health and wellbeing outcomes (Browning & Cagney, 2002; Bernard et al., 2007; Mujahid & Diez Roux, 2010). Neighborhood influence is especially important in the developmental ages; children are less mobile than adults, and therefore local neighborhoods serve as their primary social context (Moren-Cross et al., 2006). Childhood exposure to neighborhood risk factors such as poverty and protective factors such as social capital can have effects that extend into adulthood (Danese & McEwen, 2011). Developmental specialists recognize that risk and protective factors accumulate at local levels of geography to influence child and family outcomes (Leventhal & Brooks-Gunn, 2011). Together, these developments have spurred studies of neighborhood effects on an array of children’s outcomes. Although a vast body of evidence links neighborhood disadvantage with negative effects on children’s health, behavioral, and academic outcomes, little is known about how neighborhood conditions affect children’s social participation (Coulton & Irwin, 2009). Lesser still is known about neighborhood-based differences in social participation of children with and without disabilities. For example, Coulton and Irwin (2009) found that neighborhood safety and parent involvement had positive effects on children’s participation in out-of-school activities. However this study did not assess disability-based differences in participation. Several studies have demonstrated that children with disabilities participate less frequently in social activities compared with their non-disabled peers (Michelsen et al., 2009; Galvin et al., 2010; King et al., 2010; Solish et al., 2010; Bedell et al., 2013). Few studies have examined the role of neighborhood contextual factors in relation to social participation of children with disabilities. In a study of 427 children with physical disabilities living in Ontario, Canada, King and colleagues (2006) found that children’s social participation was indirectly influenced by parental perceptions of physical inaccessibility of their community, unsupportive community attitudes, and inadequate institutional services and assistance. Forsyth and colleagues (2007) used similar measures of contextual factors with a sample of 600 severely disabled children and their families living in the United Kingdom. They found that children’s social participation was influenced to a similar extent by their impairments and environmental factors such as physical accessibility, social supports, and transportation services. Conversely, Hammal and colleagues (2004) found that children’s district of residence more than their impairments explained the social participation of 476 children with cerebral palsy from Northern England. These studies provide evidence of neighborhood effects on social participation of children with disabilities. However, comparable studies in the United States are lacking. Moreover, the literature is beset by limitations such as lack of comparative analysis between children with and without disabilities, lack of samples drawn from neighborhood-based designs, and lack of both census-based measures of structural disadvantage and subjective measures of neighborhood conditions (Leventhal & Brooks-Gunn, 2000). The World Health Organization (WHO) considers participation a chief indicator of child health and development regardless of impairment or functional ability (WHO, 2007). Thus social participation outcomes allow comparisons of neighborhood effects between children with and without disabilities. With child and family services increasingly offered at the local level (Leventhal & Brooks-Gunn, 2000), evaluating neighborhood-based differences in outcomes for children with and without disabilities is critical for promoting human rights and equity and for planning effective interventions (Michelsen et al., 2009). Our study represents an attempt to address gaps in this area. Using secondary survey data from a neighborhood-based sample, we compared children with and without disabilities on social participation rates and barriers. We examined whether social participation differences between children with and without disabilities varied by neighborhood of residence. We also assessed the effect of neighborhood factors and child’s disability on social participation accounting for other child and household-level variations. ________________ Method Data Sources Our main data source was the Making Connections Cross-Site Survey, sponsored by the Annie E. Casey Foundation (AECF) and conducted by the Urban Institute and the National Opinion Research Center (NORC) at the University of Chicago. This survey was conducted between 2002 and 2011 in select low-income neighborhoods in 10 cities, nine of which were among the 50 largest U.S. metropolitan areas (Coulton, Chan & Mikelbank, 2010). In each participating city, AECF and its local partners selected designated areas (survey sites) in which a large proportion of the population was socially and economically disadvantaged (Coulton & Irwin, 2009). Survey sites included declining neighborhoods in older industrial cities (Louisville, Milwaukee, Indianapolis), poor neighborhoods with growing immigrant populations (Des Moines, Hartford, Providence), predominantly Hispanic communities experiencing persistent poverty (San Antonio), and growing, diverse neighborhoods facing housing pressures (Denver, Oakland, Seattle) (Coulton et al., 2010). Comparisons with census data suggest that the Making Connections sample approximates nationally representative urban samples on several indicators (Rawlings et al., 2007). List-assisted probability sampling was used to obtain a representative sample of households and children in each survey site. We refer to Coulton et al. (2010) for sampling frame details. Within each site, an equal probability sample of households was selected (Coulton et al., 2010). A roster of all children and adults was compiled for each household. One child per household was randomly selected as the focus child using Kish’s method, and the adult who knew the child best completed the survey (NORC, 2010). The survey was conducted in-person or via telephone in English or another language prevalent in the survey site (Coulton et al., 2010). Data were collected over three waves with a weighted response rate ranging from 69% to 79%. ‘New households’ were added to baseline samples at subsequent waves. These included new families that had moved into originally sampled addresses plus a subsample of newly constructed residential buildings (NORC, 2010). We created a data set comprising data from all households that completed the survey in wave 1 and stayed in the same survey site at wave 2, plus baseline data from ‘new households’ sampled at wave 2. This yielded a cross-sectional sample representative of children (N = 2,295) living in survey sites at waves 1 and 2 from 2002 to 2007. We obtained data on neighborhood indicators by census tracts from the 2005-2009 American Community Survey (ACS). These data were linked with the survey data based on locations of households. ________________ Dependent Variable Measure Social participation. Respondents were asked if, in the last year, their child participated in organized out-of-school activities such as sports, music, dance, language classes, and youth clubs. Responses were dichotomized to indicate some participation versus none. For children with some participation, respondents reported frequency of participation as daily, 2-3 times a week, weekly, or less than weekly. For children with no participation, respondents reported reasons for non-participation. Independent Variable Measures Child characteristics. Sociodemographic variables included gender, age, and race/ethnicity. Child’s race/ethnicity was determined based on the adult respondent’s race/ethnicity. Child’s health status was based on the adult respondent’s rating of the child’s general health on a five-point scale ranging from excellent to poor. Disability status, a dichotomous variable, was determined by a question that asked whether a health professional had ever told the respondent that their child had a physical, learning, mental, or chronic health condition that limits his/her participation in age-expected activities. Respondents were asked to report their child’s primary health condition. Child’s health insurance coverage was a dichotomous variable measuring whether the child was covered under any health insurance. Household characteristics. We included a continuous measure of household size. We also included measures of household economic resources and household-neighborhood connectedness. Household income was defined as total annual income from any sources. Household hardship was derived from four questions which asked if, in the previous 12 months, the respondent and their family had experienced: difficulty filling a prescription for drugs, difficulty paying mortgage/rent/utility bills, repossession of belongings due to non-payment of bills, or insufficient money to buy food. A response of ‘yes’ to any question was classified as ‘some hardship’; a response of ‘no’ to all questions was classified as ‘no hardship’. Home ownership was dichotomized based on whether any household member owned or held a mortgage on the property where he/she lived. Similarly vehicle ownership was dichotomized based on whether any household member owned a dependable vehicle. Household education level was based on the highest level of education attained by the respondent. Households’ connectedness with their neighborhood was measured using two variables. First we used a continuous measure of the total number of years each respondent had lived in that neighborhood. Second, a measure of household neighborhood commitment was generated using three questions that asked if, in the previous 12 months, any household member had taken steps to address neighborhood problems or for neighborhood improvement. Examples included getting together with neighbors, talking to a religious leader, or speaking with a local political official. A response of ‘yes’ to any question classified the household as ‘committed’; a response of ‘no’ to all questions classified the household as ‘not committed’. Neighborhood characteristics. Our data set included 20 project-designated sub-areas (henceforth referred to as neighborhoods) across the 10 survey sites (1 to 4 neighborhoods per site). The mean number of households per neighborhood was 114 (range 19-244). Previous analysis of Making Connections data has shown moderate reliability for neighborhood scales aggregated at this geographic level (Coulton et al., 2004). Following Coulton and Irwin’s (2009) methods, we used two types of neighborhood measures: perceptions and structural variables. Neighborhood perception variables. Multi-item scales measured perceptions of four neighborhood attributes: social cohesion and trust, shared expectations for informal social control, neighborhood safety, and disorder and incivility. The social cohesion scale comprised five items (e.g. “I live in a close-knit neighborhood”, “People in my neighborhood can be trusted”) with five response options ranging from ‘strongly disagree’ to ‘strongly agree’. The informal social control scale included five items (e.g. “If a fight broke out in front of their house, how likely is it that your neighbors would do something about it?”) with five response options ranging from ‘very unlikely’ to ‘very likely’. The safety scale contained six items (e.g. “I feel safe at home at night”, “On Halloween, most children go trick-or-treating”) with seven response options ranging from ‘very strongly disagree’ to ‘very strongly agree’. The disorder and incivility scale comprised seven items about gang activity, prostitution, graffiti, and related activities with seven response options ranging from ‘does not occur’ to ‘very common’. All scales demonstrated acceptable reliability at the individual level (Cronbach's α > .70). The composite score for each scale was the average rating across all items. Individual responses were aggregated to obtain a neighborhood level rating for each perceived attribute. Neighborhood structural variables. We included six variables associated with structural disadvantage and social disorganization (Browning & Cagney, 2002; Coulton & Irwin, 2009). Structural variable measures included: percent families below poverty level, percent population (20-64 years) unemployed, percent owner-occupied housing units, percent single parent households, percent households that moved in last five years, and racial/ethnic mix (percent population that is Non-Hispanic White, African American, and Hispanic). Data for these variables were extracted at the census tract level from the 2005-2009 ACS estimates for small areas. These five-year estimates, known to be reliable for small geographic areas (U.S. Census Bureau, 2008), offer the closest overlap with survey period, which spanned 10 years from 2002 to 2011. Census tract data were summed within neighborhoods and weighted by census tract population size to obtain neighborhood level structural variables. The mean number of census tracts per neighborhood was seven (range 1-26). Data Analysis Cross tabulations and χ2 tests were used to assess differences in rates of social participation and barriers to social participation between children with and without disabilities. To assess the effect of child, household, and neighborhood factors on social participation we estimated multivariate logistic regression models using the SAS surveylogistic procedure and the Taylor series linearization method for variance estimation. Survey site was specified as the stratum variable and neighborhood was specified as the primary sampling unit. This procedure is recommended to account for complex survey design and survey weighting for binary outcomes. In addition, finite population correction factor was specified since the sample fractions in some neighborhoods exceeded 5% of the neighborhood population. Three models were estimated – the first included child level covariates, the second included child and household level covariates, and the third model included covariates at child, household, and neighborhood levels. All child level factors were conceptually important and therefore were included in multivariate analyses. All household characteristics except household income (omitted due to low response rate) were included in multivariate analyses. The household hardship variable served as a proxy measure of household financial status. Neighborhood characteristics were selected using the purposeful selection strategy (Hosmer & Lemeshow, 2000). We conducted bivariate logistic regressions between each neighborhood characteristic and social participation and selected covariates based on the Wald test and p-value cut-off point of 0.3. We also tested for interactions between disability status and each child, household, and neighborhood level variable. Interaction terms were selected for multivariate analyses based on the Breslow-Day test and p-value cut-off point of 0.05. The Hosmer-Lemeshow Goodness-of-Fit test was used to assess the adequacy of each model. To test the sensitivity of the final model, which included covariates at all three levels, we estimated a logistic regression model with the dependent variable (child’s social participation) specified as ‘weekly’ and ‘less than weekly’. Finally, to compare rates of social participation for children with and without disabilities by place of residence, we estimated a separate logistic regression model which included child and household level covariates along with interaction between child’s disability status and survey site. Neighborhood level variables were excluded to avoid problems with multicollinearity. Children with missing responses for any independent variable were excluded in multivariate analyses. All analyses were conducted using SAS 9.2 software. The Office for the Protection of Research Subjects at the University of Illinois at Chicago reviewed and approved this study under the expedited category. Results We analyzed data for 2,295 children aged 3 to 17 years. Data were provided by adult caregivers, who were mostly parents (87%), predominantly female (81.7%), and largely young adults (average age = 33.2, SE = 0.45). Sample Description Descriptive characteristics of the sample are summarized in Table 1. Of the 2,295 children, 15.6% (n = 341) were identified as having a disability. Specific diagnostic condition was available for only 66% (n = 226) of children with disabilities. The most prevalent conditions included chronic health conditions such as asthma, diabetes, and heart conditions (n = 81), ADD/ADHD or other behavior disorders (n = 69), learning disabilities (n = 32), speech impairments (n = 23), neurodevelopmental disabilities such as autism, cerebral palsy, and spina bifida (n = 8), sensory impairments (n = 8), and mental or emotional illness (n = 5). Sixty caregivers classified their child’s primary condition as ‘other’. Table 1: Sample Characteristics (Weighted Analysis) Characteristics All a (n=2295) Without Disability a (n=1939, 84.4%) With Disability a (n=341, 15.6%) Test statistic, p-value % (SE) % (SE) % (SE) Gender (n=94 missing) Male Female 48.4 (1.6) 51.6 (1.6) 46.5 (1.7) 53.5 (1.7) 57.2 (5.0) 42.8 (5.0) χ2 = 4.03 p = 0.04 Child Age (n=23 missing) Preschool Elementary School Middle School High School 25.9 (1.4) 37.3 (1.5) 27.3 (1.5) 9.4 (1.1) 27.6 (1.5) 37.5 (1.6) 25.7 (1.6) 9.2 (1.0) 17.4 (2.8) 35.0 (4.1) 36.7 (4.5) 10.9 (4.3) χ2 = 6.07 p = 0.11 Race (n=27 missing) Non-Hispanic White Non-Hispanic Black Hispanic Asian Other 14.3 (0.9) 26.4 (1.1) 39.5 (1.5) 4.6 (0.4) 15.1(1.4) 13.5 (0.9) 26.7 (1.2) 41.2 (1.6) 5.2 (0.5) 13.4 (1.3) 18.8 (3.0) 24.8 (3.2) 30.3 (3.9) 1.6 (0.6) 24.6 (5.4) χ2 = 14.2 p = 0.007 Health Status (n=9 missing) Excellent Good-Very Good Poor-Fair 46.3 (1.5) 46.1 (1.5) 7.6 (1.0) 50.0 (1.7) 45.1 (1.7) 4.9 (0.8) 26.6 (4.1) 51.3 (4.6) 22.1 (4.5) χ2 = 22.57 p < 0.0001 Child Insurance Coverage (n=28 missing) Yes No 85.8 (1.3) 14.2 (1.3) 84.4 (1.5) 15.6 (1.5) 92.7 (1.9) 7.3 (1.9) χ2 = 9.7 p = 0.002 Household Hardship (n=29 missing) Some hardship No hardship 56.5 (1.6) 43.5 (1.6) 54.6 (1.7) 45.4 (1.7) 67.1 (3.9) 32.9 (3.9) χ2 = 6.81 p = 0.009 Household Income (n=242 missing) $0-$9,999 $10,000-$19,999 $20,000-$29,999 $30,000 or more 28.1 (1.7) 27.7 (1.5) 20.5 (1.3) 23.7 (1.3) 25.8 (1.7) 28.1 (1.7) 21.2 (1.4) 24.9 (1.4) 40.7 (5.2) 25.5 (3.8) 17.2 (3.1) 16.6 (2.8) χ2 = 10.9 p = 0.01 Home Ownership (n=12 missing) Yes No 30.2 (1.4) 69.8 (1.4) 29.7 (1.5) 70.3 (1.5) 34.1 (4.1) 65.9 (4.1) χ2 = 0.93 p = 0.34 Car Ownership (n=32 missing) Yes No 69.4 (1.5) 30.6 (1.5) 72.0 (1.5) 28.0 (1.5) 56.8 (4.8) 43.2 (4.8) χ2 = 6.97 p = 0.008 Highest level of educational attainment in household (n=36 missing) Less than high school High school/GED Greater than high school 38. 6 (1.6) 34.9 (1.5) 26.5 (1.2) 37.0 (1.7) 36.2 (1.6) 26.7 (1.4) 47.9 (4.7) 27.4 (3.8) 24.7 (3.2) χ2 = 5.79 p = 0.06 Neighborhood Commitment (n=32 missing) Committed Not committed 32.5 (1.4) 67.5 (1.4) 31.9 (1.5) 68.1 (1.5) 36.0 (4.1) 64.0 (4.1) χ2 = 0.83 p = 0.36 Years in Neighborhood (n= 1 missing) b 8.95 (.38) 8.77 (0.36) 9.97 (1.44) F = 0.65 p = 0.42 Household Size b 4.87(0.07) 4.83 (0.06) 5.04 (0.28) F = 0.52 p = 0.47 a Frequencies in the ‘All’ column are not always the exact sum of frequencies in the ‘With Disability’ and ‘Without Disability’ columns due to missing data on disability status (n=15) b Data reported as mean and standard error Neighborhood Description The average neighborhood safety rating (N = 20) was 4.34 (SD = 0.37) on a seven-point scale, with a higher score indicating greater perceived safety. The average disorder and incivility rating was 2.82 (SD = 0.43) on a six-point scale, with a higher score indicating greater disorder. The average ratings for informal social control and social cohesion were 3.24 (SD = 0.22) and 3.08 (SD = 0.20) respectively, both measured on a five-point scale with a higher score signifying better conditions. Neighborhoods experienced poverty rates ranging from 11.4% to 83.4% (mean = 33.6%, SD = 15.6). The average unemployment rate ranged from 7.4% to 28.1% (mean = 14.9%, SD = 6.0). The proportion of single parent households ranged from 8.8% to 63.4% (mean = 22.9%, SD = 12.2). Residential stability varied across neighborhoods. On average, 36.4% (SD = 18.1) of housing units were owner-occupied (range 6.4%-62.7%) and 39.4% (SD = 6.4) of neighborhood residents had moved in the last five years (range 26.8%-50.3%). The average neighborhood was 26.7% Non-Hispanic White (SD = 21.4), 27.9% African American (SD = 25.7), and 36.1% Hispanic (SD = 26.2) with the remainder classified as ‘Other’ race. Social Participation Rates Half of all children in our sample (50.3%) reported some participation in organized out-of-school social activities. Site-specific participation rates varied from 43.9% in San Antonio to 62.8% in Denver. Participation rates (dichotomized as ‘some’ versus ‘none’) varied between children with and without disabilities. Fifty-two percent of children without disabilities reported some social participation compared with 42% of children with disabilities, χ2 = 3.84, p = 0.05. Among children with some participation, we compared children with and without disabilities in terms of frequency of social participation (daily, 2-3 times per week, weekly, less than weekly) and found no significant differences, χ2 = 2.67, p = 0.45. Barriers to Social Participation On average, children in both groups reported 1.2 barriers to social participation (SD = 0.08 for children with disabilities, SD = 1.19 for children without disabilities). The most common barriers (unweighted) included child being too young to participate in out-of-school activities (n = 309), lack of opportunities in the area (n = 151), transportation problems (n = 148), and inability to afford program fees (n = 143). The proportion of respondents reporting age (child not old enough) as a barrier was higher for children without disabilities (33.8% compared to 12.9% of children with disabilities, p < 0.0001). Proportion of respondents reporting disability as a barrier was higher for children with disabilities (19.0% compared to 4.8% of children without disabilities, p < 0.01). Other barriers reported more frequently for children with disabilities included program unavailability, unaffordability, waiting lists, and safety concerns. These differences were not statistically significant. Effect of Child, Household, and Neighborhood Factors on Social Participation Model 1: Child level factors. Our first estimated model included child level characteristics (Table 2). In this model, gender and health status were not significantly associated with social participation. On the other hand, age, race, disability status, and health insurance coverage significantly predicted social participation. Compared to middle school aged children, children in other age groups had significantly lower odds of social participation. Significant differences in social participation rates were associated with child’s race and ethnicity. Compared to White children, social participation odds were 42% lower for Hispanic children and 48% lower for children of ‘Other’ race. Social participation odds were not significantly different for White and Black children or White and Asian children. Having a disability was negatively associated with social participation. Social participation odds for children without disabilities were 1.85 times the odds for children with disabilities. Having health insurance coverage was positively associated with social participation. Social participation odds for insured children were 1.78 times the odds for uninsured children with disabilities. Model 2: Child plus household level factors. Household level variables were added to Model 1 (Table 2). In this combined model, four household characteristics had positive effects on social participation – home ownership, vehicle ownership, education level, and neighborhood commitment. Children living in families that owned their home had 42% higher social participation odds while children living in households that owned a dependable vehicle had 51% higher social participation odds. Similarly, participation odds for children from households with a greater than high school education were double the odds for children from households with a less than high school education. When household members demonstrated neighborhood commitment, children’s social participation odds increased 85%. Other household level variables such as size, hardship, and length of time in the neighborhood did not significantly predict social participation. The addition of household level variables did not change coefficients for child level variables except race/ethnicity. In the combined child and household model, the coefficient for Hispanic race/ethnicity (compared to White race/ethnicity) was no longer significant. The negative effect on social participation of belonging to this racial/ethnic group (seen in the Model 1) could be attributable to household level socio-economic characteristics correlated with race/ethnicity. Model 3: Child, household, and neighborhood level factors. Neighborhood level variables were added to Model 2 (Table 2). Length of time in the neighborhood was dropped from this model as it was not statistically significant and impaired model fit. This combined model had the best fit among all three models as indicated by results of the Hosmer-Lemeshow Goodness-of-Fit test, supporting the combined effects of child, household, and neighborhood factors on social participation. The neighborhood variables measuring disorder and incivility, poverty level, housing occupancy, and racial/ethnic mix were statistically insignificant in this model. Neighborhood safety had a significant positive effect on social participation. A unit increase in perceived safety was associated with three times higher social participation odds. Conversely, residential instability had a significant negative effect. Social participation was 93% less likely with every unit increase in the percentage of households that moved in the last five years. The addition of neighborhood level variables did not cause notable changes in coefficients for child and household level variables except child gender. Being female was significantly associated with 34% higher odds of social participation. This suggests that gender-based participation differences might be attributable to neighborhood characteristics that hinder participation of boys more than girls. Table 2: Logistic regression models showing the relationship between individual, household and neighborhood characteristics and the probability of social participation. Characteristics Model 1 Model 2 Model 3 OR (95% CI) OR (95% CI) OR (95% CI) Child Level Gender: Females vs. Males 1.23 (0.93 - 1.62) 1.31 (0.99-1.74) 1.34 (1.01-1.78) * Child Age: Preschool vs. Middle School Elementary School vs. Middle School High School vs. Middle School 0.11 (0.07 - 0.17) + 0.46 (0.32 - 0.66) + 0.55 (0.32 - 0.95) * 0.09 (0.06-0.14) + 0.41 (0.29-0.59) + 0.49 (0.29-0.82) ** 0.09 (0.05-0.13) + 0.41 (0.29-0.6) + 0.48 (0.28-0.82) ** Race/Ethnicity: Black vs. White Hispanic vs. White Asian vs. White Other vs. White 1.08 (0.72 - 1.62) 0.58 (0.38 - 0.87) ** 0.7 (0.4 - 1.21) 0.52 (0.29 - 0.93) * 1.15 (0.74-1.77) 0.69 (0.44-1.08) 1.06 (0.57-1.97) 0.55 (0.31-0.99) * 1.31 (0.82-2.08) 0.73 (0.43-1.25) 0.92 (0.48-1.76) 0.6 (0.32-1.13) Disability: Without Disability vs. With Disability 1.85 (1.17 - 2.93) ** 1.68 (1.1-2.59) * 1.68 (1.08-2.6) * Child Health: Excellent vs. Poor/Fair Good/Very Good vs. Poor/Fair 1.73 (0.96 - 3.1) 1.52 (0.86 - 2.67) 1.69 (0.92-3.1) 1.53 (0.86-2.74) 1.68 (0.9-3.12) 1.55 (0.86-2.81) Child Insurance Coverage: Insured vs. Uninsured 1.78 (1.15 - 2.76) ** 1.73 (1.07-2.8) * 1.79 (1.09-2.94) * Household Level Household hardship: None vs. Some 0.93 (0.69-1.25) 0.93 (0.68-1.26) Home ownership: Yes vs. No 1.42 (1.01-1.98) * 1.47 (1.04-2.17) * Vehicle ownership: Yes vs. No 1.51 (1.05-2.16) * 1.5 (1.03-2.17) * Household education: >High School vs.